A Comparison of Quality of Life and Support Mechanisms After Childhood Burn Injures in Asian and European Countries : A Systematic Review

Background: Childhood burns are the leading cause of unintentional injuries, with more incidences in Asian than in European countries. This systematic review aims to compare the differences in extent and type of burns in children from Europe and Asia, along with the differences in the coping strategies and the quality of life these children possess after the event of the burn. Methods: This systematic review was conducted along the PRIMSA guidelines. We systematically searched DOAJ, Google Scholar, Ingentaconnect, Jurg, Popline, Prof Search, Pubmed, Pubmed Abstract, Pubpsych, Pakmedinet and PMC on 10th May 2016. Studies were selected if they met the following criteria: (1) must be based in Asia or Europe (2) must be related to burns (3) must be related to children (4) must not be treatment specific (5) must be in English (6) must be a published in a journal (not in a 1 4 Year MBBS Student, KEMU, Lahore 2 4 Year MBBS Student, KEMU, Lahore 3 Chairperson and Head of Department, Community Medicine, King Edward Medical University, Lahore Date of Submission: 17-8-2016 Date of Acceptance for Publication: 29-10-2016 Conflict of Interest: None Funding Source: None


Introduction
2][3] The incidence of childhood burns is greater in developing Asian countries as compared to European Countries, where public awareness of child safety measures is greater. 4,5Numerous researches have attempted to explore the different dimensions of how a burn attained during ones early years affects them throughout life. 6A smaller number has explored psychosocial support mechanisms for these children. 7 disproportionately larger contribution to the literature relating to this topic was made by European Institutes.In this Systematic Review, we have compared the body of work originating from Asian and European Countries and attempted to consolidate the findings.This comprehensive review will benefit medical professionals and parents in designing/implementing newer mechanism to improve QOL of the children affected by burns.Moreover, no systematic review has been done on this topic.We aimed to compare three areas.First, differences in extent and type of burns in children from Europe and Asia.Second, differences in coping strategy the children with burn undergo in these two continents.Thirdly, differences in the quality of life for these children post treatment.

Search Strategy and Selection Criteria
This systematic review was conducted in accordance with the PRIMSA Checklist guidelines. 8To identify eligible studies we searched DOAJ, Google Scholar, Ingentaconnect, Jurg, Popline, Prof Search, Pubmed, Pubmed Abstract, Pubpsych, Pakmedinet and PMC on 10th May 2016.We used Mesh terms to search those studies: -Childhood burn‖.-Extent of Childhood Burn‖, -Childhood Burns in Europe‖, -Childhood Burns in Asia‖, -Childhood Burns and Quality of Life‖, -Types of Childhood Burns‖, -Quality of Life after Treatment of Childhood Burns in Europe and in Asia‖, -Childhood burns in Developed Countries‖ and -Childhood Burns in Developing Countries.‖No limits regarding language or publication were applied.The selection and exclusion of papers is shown in figure 1.
Authors independently reviewed citations, abstracts and full articles to select eligible studies for review.Consensus was used to resolve disagreements on the eligibility of abstract reviews.Studies were selected if they met the following criteria: (1) must be based in Asia or Europe (2) must be related to burns (3) must be related to children (4) must not be treatment specific (5) must be in English ( 6) must be a published in a journal (not in a conference).

Data Collection Tool
MHM and SK developed a self-made proforma on the basis of our research protocol and we used this proforma to extract data from individual 12 studies.The proforma included differences in extent and type of burns in children from Europe and Asia, differences in the coping strategy and the quality of life these children possess after the event of the burn.

Data Extraction
Data were extracted for the mean duration of hospitalization, extent of burns in Europe, extent of burns in Asia, coping strategy in Europe, coping strategy in Asia, quality of life of pediatric burn victims in Europe, quality of life of pediatric burn victims in Asia, psychosocial effects in Europe, psychosocial effects in Asia, family of burn victims in Europe, family of burn victims in Asia, educational impact post burn in children from Europe, educational impact post burn in children from Asia, posttraumatic stress disorder among burned children from Europe, post-traumatic stress disorder among burned children from Asia, post-burn pain among burned children from Europe and postburn pain among burned children from Asia.

Synthesis of Results
Synthesis of results was done manually by MHM and SK.A forest plot showing the duration of hospitalization was made on Microsoft Excel by MHM using the means from different studies.

Results
Of 603 studies screened, 26 were considered potentially eligible (Figure 1).Fourteen trials were excluded because they assessed childhood burns outside Europe and Asia.We used 12 studies to do this systematic review and 5 out of 12 studies to do meta-analysis.Titles of these 12 studies are shown in figure 1   from Bangladesh and 1 was from India.The Vann diagram shows the topic addressed by these articles.

Statistical Analysis
We used 5 studies to find average length of hospital stay out of which 2 were from Asia and 3 were from Europe.Length of hospital stay was plotted as forest plot (figure 3).It showed no significant difference between duration of hospitalization in two continents which depends only on the severity of burns.

Findings Extent of Burns in Europe
Across two studies 9,10 it was demonstrated that in Europe, male children were almost twice as likely to suffer a burn injury as compared to female children.Burns involved various areas of the body including face, chest, arms, hands, torso, thighs, buttocks, and feet. 10he total body surface area affected by burns ranged from 1.5 to 13% 10 the average body burn was 11.9%. 3cross the articles facial involvement in European pediatric burns ranged from 44.2% 9 to greater than 50%. 4A majority of the burns suffered by the paediatric population where scalds (51.2% 9 and 90.7% 3 ), in one article 34.9% of burns were due to fire. 9Of all children who had skin grafts following burn injury, only 25.6% required more than one skin graft. 9Mothers were present at the time of injury in 46% of incidences. 9Only two articles explored the socioeconomic determinant of burns in these European countries; both showed that almost half of all children with childhood   burns came from middle class families and surprisingly only 11.6% to 13% of children with burns were from lower class backgrounds.

Extent of Burns in Asia
In Asian countries, approximately 2/3 rd of paediatrics burn victims are female (62%). 5A disproportionate percentage (80%) of childhood burns occur in villages. 5Fire is the biggest contributor (68%) to burns followed by electrocution (11%).Scalds make up a mere 8% of all burns. 5The majority of these burn victims come from poor socioeconomic backgrounds. 6Only 2% of burns lead to permanent disability; 65% of them were due to injury to arms and hands. 692% of burns were not hospitalized. 6It was also mentioned that 50% of burns happen to the leg and thigh, 25% to the arms and hands and 12% to abdomen/pelvic regions.

Coping Strategy in Europe
The coping strategies in Europe for children with bur- ns are: compression therapy (100%), splints (34.9%), physical therapy (30.2%), occupational therapy (20.9%), psychotherapy (4.7%) and plastic and reconstructive surgery (18.6%). 9Compression garments were used in severe burns. 7It was found that more agreeable personalities had poorer coping strategies 8 and that children with burns have greater coping abilities than controls. 8,9ping Strategy in Asia Coping strategies mentioned included wound breakdown, dressing changes, exercises, splints, pressure garments, a hypothetical burn camp for interaction of burn children and child psychiatrist.The articles did not elaborate the percentage of the paediatric burn victims used these.

Quality of Life of Paediatric Burn Victims in Europe
With regards to quality of life for burn victims from the paediatric population we found that articles differed in the outlook they presented.The dominant view is that children who recovered from burns have near normal health related quality of life (HRQOL). 9It was also suggested that social functioning was the deficiency that was present and this was mainly the outcome of the negative reactions that others showed upon seeing their burn scars. 9Other studies show that most parents report that their children mostly complain about Itch and appearance. 106% of parents reported mobility issues, 9% of parents reported problems with their children being able to take care of themselves and 11% of parents said their children could not preform normal activities. 1018% of children reported pain/discomfort and 20% reported anxiety and depression. 10It must be mentioned that reporting of suboptimal outcomes most frequently would occur if parents had a child with extensive burns, recent burns or a daughter who suffered from burns. 10

Quality of Life of Paediatric Burn Victims in Asia
In Asia 16% of patients require assistance with daily activities for one to three months. 619.9% of children missed school for extended period of time. 68.9% of burnt children were working and of them 18% were absent from work for 1 -3 months. 6Reconstructive surgery began mostly one year following the burn inj-ury and continued for many years. 6It was found that for treatment of severe burns, the family needed to spend $462. 11This is a significant amount considering majority of families in this region whom have the misfortune of having their children suffer burns are often earning $67 a month. 6

Psychosocial Effects in Europe
Amongst this paediatric population 20.9% of patients remembered the event in which they were burnt and 25.3% remembered hospitalization.Also, 23.1% showed fear of hot water and fires, whilst 42.9% are just cautious.20% of children with burns had difficulties in contact with members of the opposite gender, 33% would hide scars in public and 5.5% of children with burns had no memories of how they got their scars.It was noted that post-burn people do not have any issue with hypo-pigmentation. 3 Victims of childhood burns complained of disturbed sleep, depression and anxiety, made worse by the uncertainty of recovery.This had the knock on effect of causing parental anxiety.Professional care that promoted physical recovery was found to relieve parental anxiety and parents rated it as ‗Ideal Care'.Soon after slight physical and psychological recovery, children were eager to return to normal life; like going to school, but the main barriers remained i.e. psychological issues arising from altered physical appearance and situational changes.The mothers of these children professed that they felt guilty and were over-cautious with respect to that child. 8others were present during the burn event 46% of the time. 9It was noted that personalities that were less agreeable, had better passive coping skills, as did children burned during infancy and young girls. 8,12After 10 years, adolescents with childhood burn were no longer at risk of depression and behaviour changes. 16motional stability is an important factor for recovery after burn. 16,21Severely burned children have more behavioural issues. 23Some post burn people have difficulty in choosing profession. 11Adolescents with facial burns have poor self-image that those with congenital defects. 22,23tients would be more likely to remember the period of hospitalization and have memories of the pain if they were older than 3 years at the time of burn.With regard to ICU burn patients 28.6% had memories of pain, 14.3% remembered the incident and 42.9% had memory of hospitalization.

Psychosocial Effects in Asia
Psychotherapy of paediatric burns aims to overcome anxiety, stigma, promote positive self-image, help children come to terms with their situation and assist reconstruction and rehabilitation.However, burn centres have limited funds for psychosocial services.The therapeutic strategy is breaking links between cognition, emotion and behaviour.Then it is desired to replace them with more adaptive thought and behaviour patterns through cognitive behaviour therapy, family support therapy, psycho-education and psychopharmacology. 19All psychosocial effects are worsened by the fact that children with burns looked more normal at acute discharge than one year post burn. 11

Family of Burn Victims in Europe
The guilt and anxiety experienced by parents throughout both the burn and the healing process led them to question their ability to be good parents.Parents often expressed being unable to effectively protect their children and would became over anxious when allowing their children to be involved in activities that could be dangerous in any way.

Family of Burn Victims in Asia
Burns place an immense strain on families, whether it is the loss of working hours or physical stress and PT-SD in children. 13arental inadequacy during the event of the burn is a major and recurring problem being reported.60% of children with burn are treated by unqualified health service providers.Unqualified health service providers include: Medicine shopkeepers (44% parents sought their help), traditional healers and homeopaths (5%), friends and relatives (5%) and herbal medicine practitioners (more than 5%).This trend is understandable considering that burns in Asian countries mostly affect rural people (64.1%)where families are often poor (66.5%), and illiterate (72.5%).][26][27][28] Only 40% of burn victims seek professional care, 23% are taken to hospitals and 17% are seen by registered medical practitioner.A families' first born is more often taken to qualified service providers than the following children and parents with 2 or less number of children are more likely to visit qualified service provider.
Sometimes parental inadequacy is in fact abuse of a child. 19,29Abused children have complications thro-ughout their recovery related to family dysfunctions.Health professionals tend to continue working with the family of the abused child, sometimes including the abuser stating that not doing so would not change the fact that the child often returns to the family.

Educational Impact Post Burn in Children from Europe
A strong factor in return to education for a child with burns was the degree of support the school offered during the child's period of absence.A lack of contact from the school was seen as especially important when children were studying for their GCSEs.Government agencies played important roles in helping children return to school without exacerbating the parental stress by connecting the burn care team with school professionals to create the initial bridge between the child and normality.51.7% of patients did achieved good or excellent marks in their last school reports.Interesting it seemed that children with burns were more likely to gain educational qualifications that the population as a whole.70% of female burn victim and 92.9% of male burn victims gained qualifications, whereas for the rest of the population at the same time period (1992) the average for both genders was 46.9%.

Educational Impact Post Burn in Children from Asia
Studies exploring this impact have not been performed.

Post-Traumatic Stress Disorder among Burned Children from Europe
Post-traumatic stress disorder (PTSD) is higher among burned children than in normal population and 18.6% of burned children are later diagnosed with PTSD.Interestingly, presence of mother at the time of accident shows less symptoms of PTSD. 29

Post-Traumatic Stress Disorder among Burned Children from Asia
Studies exploring this impact have not been performed.

Post-Burn Pain among Burned Children from Europe
In Europe, moderately burned children shows greater post-burn perceptual sensitization than controls and severely burned children.Second degree burns are very painful. 7,30Moderately burned children experience short period of intensive pain while severely burned children experiences long period of intensive pain. 7Severe burn during infancy decreases stress induced activation of endogenous pain inhibition.

Post-Burn Pain among Burned Children from Asia
Studies exploring this impact have not been performed.

Discussion
This systematic review of quality of life and support mechanisms for children who have survived burns, has the following findings: Firstly the characteristics of burns in these two regions are very different.European children are far more likely to be burnt by scalds, whereas Asian children are most likely to be burnt be fire.This has the implication that burns suffered in Europe were more likely to be superficial.Burns in Europe is also most likely to affect middle class families as compared to Asia where low class families are most at jeopardy of having a family member suffer burns.Another interesting characteristic is that in Europe boys are more likely to suffer burn injuries; however in Asia, girls are the predominant victims.
Secondly European children have access to significantly better after care that is aimed at both improving health related quality of life and helping the patient attain independence.A point exemplified by the offering of occupational therapy.In Asian countries very few burn victims have access to psychiatrists.
Research discussing quality of life for European children post burn emphasized on anxiety, pain and social functioning.However, amongst Asian children the emphasis was on loss of daily activities, school, working hours and the financial toll of treatment on the family.From these differing foci it is clear that the superior social welfare offered in Europe is keeping families is a far more stable situation as their counterparts in Asia.
Psychosocial affect from burns on both the child and their parents was comparable in the two regions.Some children reported traumatic memories and others expressed behavioural issue.Parents in both regions expressed a sense of guilt and anxiety which was only alleviated to a major degree when their child was able to return to normal daily activities.
With regards to family life after burn of a child, we found that in both regions parents expressed immense guilt and would be reluctant to trust that their children could take care of themselves.This was expressed by parents reporting increase anxiety when their child would desire to perform a task that was remotely dangerous.In some of the articles from Asian countries issue of child abuse were raised along with the dilemma of medical teams in working with suspected abusive parents.It would seem that adequate lack presence/implementation of child protection laws means that cycle of abuse is being allowed to continue.
It was also seen that burn victims would make up for time lost from school and that they would typically go on to complete professional qualification at rates above the national average of their respective countries.It was made clear that role of interagency bodies and schools were important in creating an easier situation in which children with burns can successfully retransition back to school.The impact of burns in the paediatric population on education has not been explored in Asia.
Post-traumatic stress disorder (PTSD) was explored in European countries.It findings were that 18.6% of children who suffer burns will attain PTSD and that those children whose mothers were not present at the time of the incident were also more likely to get PT-SD.
Finally, European countries also explored altered perception of pain in children who had experience burns.They found that infants who experienced severe burns had a reduced pain threshold in later life due to decreased activation of endogenous pain inhibition.In addition to this finding, articles showed that some moderately and severely burned children would have bouts of intense pain; which would last considerably longer in severely burned patients.

Fig. 2 :
Fig. 2: Venn diagrams showing the topics related to burns covered by the Articles.
. We found four articles from Asia and eight from Europe as shown in table 2. Of the 4 articles from Asia, 3 were 326 ANNALS VOL 22, ISSUE 4, OCT.-DEC.2016

Table 1 :
Article number and titles of selected articles.
330Psychological Aspects of Paediatric Burns (A Clinical Review) 336 Quality of life after burns in childhood (5-15 years): Children experience substantial problems 357 Self-and parent-perceived stigmatisation in children and adolescents with congenital or acquired facial differences

Table 2 :
Shows regions to which the articles belong.